This study reveals new (Level II) evidence that cesarean surgery should not be the automatic go-to option for twin births. In my local community, there has been a strong trend to steer mothers of multiples into the surgical suite with hardly a pause to consider the benefits of vaginal birth (although most recently, a few maternity care providers here have begun to push back against that practice and support women of twins through vaginal births).

This meta-analysis published in the same journal reveals a link between low gestational weight gain and pre-term birth, as well as low birth weight infants. I recently wrote on the topic of poor weight gain during pregnancy–especially as it pertains to pregnant teens.

Whether due to tocophobia (fear of childbirth), financial constraints, career pressures or other factors facing women of childbearing age, an interesting trend has emerged as the U.S. 2010 census results have been released: birth rates in our country have dropped, according to this USA Today article.

And have you heard? South Carolina is the latest state to put a stop to early, elective cesarean deliveries—following on the heels of Oregon’s commitment to the same cause earlier this month.

In the current American Journal of Obstetrics and Gynecology issue, a compelling cohort study suggested the persistent need for maternity care providers (and those interacting with pre-/interconceptional women) to increase educational efforts with women trying to conceive. The study found that women attempting conception were decreasing their caffeine intake, but were not significantly changing/ decreasing nicotine and alcohol use. Study authors conclude more preconceptional guidance is warranted for the interpartum or pre-conception population.

Also in AJOG, is the presentation of study findings suggesting that epistiotomy does not, in fact, reduce the incidence of brachial plexus injury in the event of shoulder dystocia. Data were collected from 94,842 births between 1998 – 2009. During the study period, epistiotomy rates dropped from 40% to 4% with no change in brachial plexus injury rates, per 1,000 births. Authors of the study conclude that, “despite historical recommendations for an episiotomy to prevent brachial plexus injury when a shoulder dystocia is encountered, the trend we observed does not suggest benefit from this practice.”

And in the journal Birth, Marian MacDorman, Eugene Declercq, and T. J. Mathews reported on the 20% increase in home birth rates in the U.S. from 2004 – 2008. You can access the full article here.

So, what’s on your radar? What have you read with interest lately? Please do share with your fellow readers what you’re reading and keeping an eye on.

[Editor’s note: This article by Amy Romano was originally posted on Childbirth Connection’s Transforming Maternity Care site, September 12, 2011 and is re-purposed with permission.]

When I recently updated Childbirth Connection’s VBAC or Repeat C-Section Topic to reflect the findings of a government-sponsored systematic review and national consensus recommendations, I was struck by how few of the facts have changed in the years since the government’s previous VBAC evidence report. While there are more data than before, we already knew that the risks of uterine rupture in labor were about 1 in 200, that accumulating cesareans sharply increases the likelihood of life-threatening complications in future pregnancies, and that there are few situations when planned VBAC is objectively unreasonable. Although the evidence has not abated the precipitous drop in VBACs, perhaps unprecedented national consensus about the importance of prioritizing VBAC services, an increasingly savvy grassroots movement, and urgent calls from obstetricleaders will begin to move the needle.

As we shift the conversation from whether to do VBACs to how to enable more of them, focus on quality and safety in the context of VBAC is long overdue. According to new government statistics (pdf), one in five of the more than 4 million births each year in the United States occur to women who have previously given birth by cesarean. If evidence supports VBAC as a “reasonable option” for most of this population – and indeed the better option for many – it is time to be reasonable about how to make VBAC as safe, accessible, and satisfying as it can possibly be.

In the absence of nationally endorsed quality measures for VBAC, payment reform to provide better incentives to offer and achieve VBAC, and care coordination to help pregnant women navigate the health care system (all urgently needed), we turn to the broader concept of maternity care quality to offer a framework for high-quality VBAC care. We’re interested in hearing what VBAC quality improvement projects exist in your community, and are eager to feature them in our TMC Directory.

A QUALITY FRAMEWORK FOR VBAC

1. Help more women make and implement choices that are informed by the best quality evidence and aligned with their own values and preferences.

Rationale: While much attention has been given to ACOG’s “Level C” recommendation to undertake planned VBAC “in facilities with staff immediately available to provide emergency care,” this recommendation is superseded by their “Level A” recommendation to “counsel women about VBAC and offer [trial of labor]” to appropriate VBAC candidates. In addition, “decision quality,” i.e., the extent to which choices align with a woman’s stated preferences and values and available evidence, is a marker of overall health care quality. Not to mention, honoring people’s informed choices is the legal and ethical standard, acknowledged by all major health care bodies.

Current approach: Few women have a choice at all. According to the VBAC Policy Database, a voluntary monitoring project by the International Cesarean Awareness Network, half of U.S. hospitals either ban VBAC outright or have no providers willing to attend VBACs. In our most recent national Listening to Mothers survey, more than half of women interested in a VBAC were denied the option, usually because of provider refusal or hospital policies. In areas where VBACs are “offered,” women must often meet eligibility criteria that are not supported by high-quality evidence. Informed consent processes typically solicit consent for VBAC but may not provide a special consent process for repeat cesareans, despite the fact that repeat cesareans pose different and in some cases much more serious risks than first cesareans.

Why this is inadequate: Both planned VBAC and planned repeat cesarean section are reasonable choices with important potential benefits and harms but the trade-offs are very different. The current approach, which ostensibly is intended to reduce the already low likelihood of avoidable perinatal death or injury and associated liability, has resulted in significant collateral damage: most notably an increased risk of maternal mortality and a growing prevalence of life-threatening complications for both mothers and babies in future pregnancies. We are also seeing troubling care patterns, including court-ordered repeat cesareans, women laboring in hospital parking lots so they can show up just in time to give birth and avoid the pressure for a cesarean, and a sharp increase in the number of women with prior cesareans choosing to give birth at home, sometimes with no skilled provider present at all. The Agency for Healthcare Research and Quality (AHRQ) team that conducted the 2010 systematic review on VBAC versus routine repeat cesarean referred to the VBAC access issues as “chilling,” an assessment with which we at Childbirth Connection agree.

Another approach: We urgently need evidence-based, field-tested shared decision making tools to communicate the research evidence and help women clarify their preferences and values. We have seen a commitment to this approach in Canada, the United Kingdom, and Australia, but thus far nothing in the U.S. (a situation we hope to change through our Shared Decision Making Maternity Initiative). Although decision support tools can help a woman select the best choice for her, system barriers including payment incentives, liability concerns, and clinician education must be addressed simultaneously to ensure that she can implement her choice. Assessing the potential for shared decision making tools and processes to reduce liability should be a research priority.

Rationale: Morbidity in VBAC labors is concentrated in the subset of women who have unplanned repeat c-sections. These risks include infection, hemorrhage, blood clots and emotional distress. In addition, having a VBAC reduces risks in subsequent pregnancies and virtually ensures that future births will be vaginal, while having a repeat cesarean sharply increases risks in subsequent pregnancies and virtually ensures that future births will be surgical. Finally, repeat cesarean costs payers significantly more than VBAC and has significant downstream economic costs because of these effects in subsequent pregnancies.

Current approach: Clinicians and researchers seem to have responded by focusing on selecting the women most likely to have a vaginal birth. Several researchers have attempted to create prediction tools to select these women, and some clinicians and hospitals have imposed strict eligibility criteria for planned VBAC. Significantly less attention has been given to prenatal and intrapartum interventions and care processes that may enhance a woman’s likelihood of having a safe vaginal birth.

Why this is inadequate: Calculating the likelihood of vaginal birth can provide helpful information to women making an informed choice to plan a VBAC or repeat cesarean. However, even women with a lower-than-average likelihood of vaginal birth usually have a better than 50-50 chance. Moreover, some groups with lower likelihoods of vaginal birth, such as women with high BMI or multiple prior cesareans, also face significantly higher than average likelihood of harm if they end up with a cesarean. The AHRQ systematic review concluded that none of the available prediction tools adequately selected women for successful trial of labor.

Another approach: The AHRQ systematic review researchers emphasized the need to incorporate “non-medical factors” in prediction tools to enhance their usefulness. These factors, which include liability concerns, the nature and extent of informed decision-making, and provider and birth setting characteristics, appear to have a stronger effect on VBAC likelihood than factors intrinsic to the woman. In addition, research is urgently needed to identify labor care strategies to promote safe vaginal birth in women with prior cesareans, in particular the potential contribution of midwives and doulas. A randomized controlled trial examining the impact of doula care on VBAC labors is currently underway in Canada.

3. Provide the best possible response to obstetric emergencies including uterine rupture

Rationale: Uterine rupture occurs in about 4.7 per 1000 VBAC labors and is an obstetric emergency requiring prompt delivery. Although the outcome of uterine rupture is usually favorable for both infants and mothers, morbidity and mortality may be minimized if the team is prepared, communicates well, and responds quickly and in a coordinated fashion.

Current approach: The small chance of a sudden emergency with high risk of serious fetal and maternal harm resulted in ACOG’s recommendation that surgical and anesthesia staff should be “immediately available” for VBAC labors. Although in 2010 ACOG clarified that women should be able to make an informed choice for a VBAC despite this recommendation, or be referred to another facility, the response to the possibility of uterine rupture continues to favor simply prohibiting women from planning VBACs.

Why this is approach is inadequate: The singular focus on availability of a surgical team has created a situation where women in communities without these resources must consent to unwanted and potentially unneeded cesareans in order to access any maternity care at all. It also assumes that availability of surgical resources automatically translates into an optimal outcome, but unprepared or ineffective care teams may not be able to avert preventable poor outcomes despite being “available.” The AHRQ review researchers identified several other obstetric emergencies that occur with similar frequency as uterine rupture and result in similar likelihoods of serious harm but for which the obstetric community does not deem 24/7 cesarean capability to be necessary. For these obstetric emergencies, rather than forbidding labor, hospitals have begun focusing on proven patient safety strategies like enhancing teamwork, implementing checklists, and conducting drills and simulations.

Another approach: As noted above, obstetric emergencies requiring prompt cesarean delivery can happen in any labor and in any birth setting. The emerging concept of “high reliability obstetrics” provides a framework for preventing adverse events and managing them in a consistent fashion when they occur despite prevention efforts. This requires a multi-disciplinary commitment to preparedness, teamwork, communication, and documentation. Various safety courses teach teamwork and management of emergencies in obstetrics. A systematic review of multi-disciplinary simulation training found that such programs improved knowledge, practical skills, communication, and team performance in acute obstetric situations and were associated with improved neonatal outcome.

BRINGING BACK VBAC

If VBAC is a reasonable option for most women, we need a reasonable approach to ensuring quality and safety in VBAC. Like maternity care generally, transforming VBAC care will take multi-stakeholder commitment to system reform. With so much inertia in the system, consumers and advocates must maintain a strong voice to push for positive change. Our newly updated VBAC or Repeat C-section Topic and the latest data on cesarean and VBAC trends are two resources to help women and their advocates. Our Action Center provides more ideas for engaging in maternity care transformation.

The Research
Several interesting studies have recently been published in the Scandinavian journal, Acta Obstetricia et Gynecologica Scandinavica(some of which I will cover in a subsequent post). The greatest one of interest, which has garnered much media attention lately is the study about fear of childbirth which, according to researchers, has a drastic affect on increasing instrumental deliveries (51%), labor inductions (17%), and requests for elective cesarean deliveries (30%) when compared to women not suffering from this intense form of childbirth-based fear termed “tocophobia.”

The results of this relatively small study (cases=353, controls =579) out of University Hospital in Linköping, Central Sweden, are not necessarily surprising to many of us, but reiterate what many having been talkingaboutfor decades: fear has a very real affect on the process of labor and birth. In fact, in the most extreme cases, tocophobia may result in avoidance of pregnancy all together. But for our purposes, as childbirth professionals, we need to be thinking about how we approach the topic of fear pertaining to birth in our interactions with our students/patients/clients.

Take the cascade of interventions, for example: For the woman who is increasingly anxious about what will happen during labor and birth–who asks for an elective labor induction to “just get it over with,” some of the difficulties she may be most afraid of, become a self-fulfilling prophecy when her labor is complicated by the effects of labor induction (increased pain, intensity and frequency of contractions…potential negative effects of epidural analgesia when assistance with her intense pain is requested…fetal heart rate concerns…maternal blood pressure concerns…potential advancement to cesarean surgery).

Application for Childbirth Educators
Carefully and sensitively bringing up the topic of fear related to childbirth is imperative for childbirth educators: it gives our students the opportunity to express concerns which they might otherwise keep to themselves–thinking they are “the only ones” harboring such anxiety. It is not about inducing or encouraging fear, rather it is about presenting the opportunity and encouraging dialogue on this topic–offering positive perspectives and coping strategies that the woman/couple may not have come up with on their own.

Don’t be Afraid to ReferIn the event we find ourselves interacting with a woman whose fear pertaining to pregnancy and/or birth is deeper than that which we feel poised to handle in class (or in clinic), referring the woman locally to a trained professional adept at counseling her through this challenge becomes a must. Tocophobia is a very real phenomena. This study published in Clinical Obstetrics and Gynecology, 2004 (47:3) describes tocophobia as occurring in 20% of pregnancies with disabling fear occurring in 6%.

As childbirth educators and maternity care professionals, we may not have the training or skill set to appropriately handle and solve every challenge that faces an expectant woman. And when we don’t immediately posses those skill sets, we must invite the assistance of other professionals trained to do so. In the mean time, proactively delivering evidence-based information that empowers (rather than frightens or degrades) expectant women can go a long way toward building confidence and reducing fear.

New technology claims to be a ‘breakthrough in non-invasive labor progress monitoring,’ using ultrasound and GPS-like imaging to determine pelvic diameter, cervical dilation, and the position and descent of the baby. LaborPro claims that their advanced technology can reduce inaccuracies inherent in manual assessment of cervical dilation and fetal head station and position, and that the use of their technology will lead to fewer unnecessary cesarean sections. Sounds great…doesn’t it?

When I heard about this technology, I got a sinking feeling. Our grandmothers had X-rays to determine pelvic diameter. Oops, that can damage the baby. Our mothers were introduced to continuous electronic fetal monitoring to make sure that babies were coping well. Oops, that has led to an increase in cesareans without improving outcomes for babies. And now, we could be the generation that uses ultrasound and GPS to create 3D images of what is happening during labour, leading to…oops….?

LaborPro—the name sounds reassuring and promising, as if the machine has been through birth many times, like an experienced midwife. What the technology offers is so tempting…maybe clinicians would make fewer subjective decisions about labour dystocia (failure to progress) if they could SEE the baby’s head descending. Maybe they wouldn’t inaccurately assess ‘your pelvis is too small,’ if they could measure the pelvis. And yet…

Pelvic Measurements

• Pelvic measurements taken while lying down are different than if a woman is upright and moving. When a woman is on hands and knees her pelvic outlet is 0.5 cm bigger than when she is lying down, and movement also helps increase pelvic space. This can make a big difference to the ability of the baby to rotate and descend. Also, while measurements can be made to determine the space between the pelvic bones, the pelvis stretches during labour, and no one can predict how much it will stretch. Pelvic movement is one of the reasons labour hurts.

Optimal Positions and Movement During Labour

• It seems (from the LaborPro video, the way that sensors are placed, and the way ultrasound is used) that women will need to be supine or semi reclining to have LaborPro applied to them. This is the least effective position to labour in.

• It seems that during the use of the LaborPro tool, women must be stationary, as they will have sensors attached to their body. This is the least effective mode to labour in: it is more effective for women to move around freely during labour to encourage descent and optimal positioning of the fetus.

• Particularly, an extended or repeated exposure of ultrasound to the head of an infant, which houses the brain, has not been extensively studied with regards to safety for the unborn baby. The LaborPro is applied close to the unborn baby’s head during labour.

• Ultrasonography measurements with regards to fetal size are notoriously inaccurate. What makes the ultrasound machine suddenly an extremely accurate measurement of size and position?

• What happens if the sensors slip or move during the use of LaborPro? Will this create inaccurate results, leading to unnecessary interventions?

Non-Invasive?

• While LaborPro claims its technology is non-invasive, to determine cervical dilation, the technology still requires that clinicians insert a finger into the woman’s vagina. The difference with LaborPro is that a positioning sensor is attached to the clinician’s finger, so the technology can determine how dilated the woman is, rather than the clinician. This means women will continue to have vaginal exams and the use of technology, doubling up on the quantifying, measuring, left brained, logical, medical assessment without evidence of health benefits.

• Labour is largely a function of the parasympathetic nervous system, particularly the dilatation phase. Any disturbance, interference in a woman’s privacy, interruptions, or breakdown in her confidence in her ability to give birth will introduce fear into the equation. Fear counters parasympathetic functions, and slows down labour progression. LaborPro has the potential to disturb a woman’s concentration and the quiet peacefulness of a birth environment, interfere with her privacy by techs, physicians, or other staff entering and exiting her room more often than before or in a more disturbing manner because of the moving of equipment, and the potential to break down a woman’s confidence because of the implication that technology is a more trustworthy entity than the woman’s body or low tech approach by care providers. Research shows the benefits of having a low tech approach encourage favourable outcomes.

Loss of Hands-on Skills and Human Touch

• The LaborPro tool has the potential to undermine care provider hands on skills. Research (referenced and expanded upon in Atul Gawande’s book “Better”) shows that a low tech approach costs health care systems less and results in better health for patients, regardless of which area of medicine is assessed.

• In times of emergency (i.e. electrical blackout, fire), natural disaster (earthquake, flood etc.), and widespread lack of access to technology because of a rural environment, hands on skills are imperative. Surges in patient loads can lead to all machines or surgical suites being in use, along with a lack of technicians or physicians trained in using the technology.

• All medical practitioners recognize the importance of good hands on skills and human touch in medicine. Despite this, we so often look to technology to tell us what we can determine clinically. The use of a pulse oximeter is a great example: a patient’s pulse may be determined by palpating the radial artery and her blood oxygen concentration can be estimated by assessing her skin colour. The oximeter is sometimes wrong, and a quick assessment is more accurate. Good manual measurement skills will be lost if technology usurps hands on assessment via LaborPro.

• Yes, the accuracy of measuring actual centimetres dilated varies between care providers and is subjective. But knowing the exact number is not as important as assessing progress: is a woman more or less dilated than the last time I measured? And assessing the presence of remaining cervix: is the cervix fully dilated or not? Exact centimetre accuracy is less important.

Add to all these concerns the fact that NONE of the clinical trials (which were most likely funded by Trig Medical, the company selling LaborPro) showed that the technology was any better than digital examination for determining dilatation, position, and station. The research sample sizes were small, and did not include any outcome data—which means it certainly does not support or even address the claim that LaborPro will reduce caesarean sections, and there is no data on whether the health of mothers and babies are improved with the technology.

One of the selling features of LaborPro is that it automatically stores data on labour—which could then be used to defend medical personnel in malpractice suits. In fact, some have suggested that this may in fact be one of the main reasons hospitals will buy this equipment.

TrigMed is on a circuit in the US, at conventions such as ACOG 2011, Birth 2011, ISUOG 2011, and RSNA 2011. They are presenting their product to obstetricians, promising results that have no academic research behind them.

I have a better idea. Instead of implementing an expensive, untried product, which will most likely lead to more problems and misdiagnoses, let us move towards a proven approach to labour and delivery: supportive one-to-one care, allowing labour to begin on its own, and patience with the birth process. Let mothers learn to listen to their own bodies and babies, and let mothers be the ones to tell medical personnel what is happening within themselves. Let us allow nature to unfold in the way it is designed, slipping babies into the world with as little interference as possible.

The Trig Medical company has a seemingly altruistic goal in mind: to reduce the risks involved with childbirth while improving the outcome of pregnancy and lowering the overall cost of obstetrical care. Their newest product promises nothing short of this. The LaborPro is an ultrasound-based device created to accurately track fetal station and position upon entering the mother’s pelvis. Using GPS-like position tracking technology, the LaborPro promises to “improve the labor and delivery experience and outcomes of childbirth” by removing the “blind interpretation” of cervical dilation and fetal positioning by maternity care providers. In layman’s terms, Trig Medical believes maternity care providers are so in-adept at their clinical skills of measuring cervical dilation and fetal position and station, that they feel (another) technical device is warranted in the labor and delivery setting. Ultimately, the LaborPro is positioned as a tool which can reduce unnecessary c-sections and improve rates of fetal and maternal morbidity and mortality (and record progress of labor minute-by-minute in case this data becomes useful in a post-birth lawsuit).

Indisputably, there were differences between the LaborPro and clinician measurements of dilation, station and position, and yet, I can’t help but to ask, how significant were those differences? An example, provided in the study article, is the mean difference in measurement of fetal head station between the clinician’s own estimation, and that of the LaborPro. Out of (only) 59 measurements, clinician measurements were -0.8 + 0.89 millimeters different compared to LaborPro data. 0.8 millimeters is equivalent to 0.08 centimeters…less than a tenth of a centimeter. Can this difference in estimation of where the fetus lies in the mother’s pelvis really make a difference in clinical outcome? Even at its worst deviation (-0.8 + 0.89) the difference between a clinician’s estimation of fetal station is +1.69 millimeters (little more than one tenth of a centimeter). I have a hard time understanding how the knowledge of the fetus being one tenth of a station further down (or up and out of) the pelvis would actually alter clinical management of labor and birth.

“Mrs. Jones, according to the LaborPro, your baby is at negative one and nine-tenths station, rather than at o station, as we thought. We are going to need to do a cesarean section to get this baby out, safely.”

Am I the only one who thinks this is totally ridiculous?

On a more personal note, I can imagine being a maternity care provider—a doctor or midwife—well adept at assessing a woman’s process in labor, only to be approached by a company—or hospital administration—and told, ‘your clinical assessment skills aren’t nearly as good as you think they are…you need this machine to better track your patients’ progress through labor.’ Kind of demeaning, right?

And what about the non-measurement-based indicators as to where a woman (and her baby) are in labor? As I imagine any midwife and intuitively-geared maternity care provider will tell you, so much more than the results of a vaginal exam reveal how a woman’s labor is progressing: her self-derived body positioning, her vocalization, her behavior, the physical sensations she reports. Opting for more and more devices to tell us what’s going on during labor risks taking the art away from maternity care. Do we really want to trend toward a device-driven, artless approach to attending labor and birth?

And still, aside from the above-mentioned issues is the potential intrusion of yet another device to distract care providers from tending to the woman. I remember one sage piece of wisdom I heard during PA school again and again: treat the patient, not the monitor (test…scan…etc.) Investing in one more machine is tantamount to divesting in our clinical skills, our attention to the human subject before us, our concern for recorded data that might come in handy if things go poorly during a birth…we risk aiming our attentions in all the wrong places.

Maternity care providers, I urge you: Say ‘No’ to the LaborPro.

Tomorrow, you will have the chance to read another assessment of the LaborPro by Melissa Vose and Asheya Hennessey, Directors of Mothers of Change for Maternity Care